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Objectives. Recognize what aspects of the maternal history are important for a complete newborn assessmentUnderstand the basics of a newborn physical exam and familiarize yourself with normal variations and/or abnormalitiesLearn the basics of a Ballard gestational age assessmentUnderstand the imp

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an introduction to the nursery

An Introduction to the Nursery

Newborn Nursery Faculty:

Division of General Pediatrics

Photgraph: Anne Geddes

Created by: Maria Kelly MD

objectives
Objectives
  • Recognize what aspects of the maternal history are important for a complete newborn assessment
  • Understand the basics of a newborn physical exam and familiarize yourself with normal variations and/or abnormalities
  • Learn the basics of a Ballard gestational age assessment
  • Understand the importance of gestational age in the complete newborn assessment
your daily newborn responsibilities
Your daily newborn responsibilities…
  • Please see the document “Newborn Orientation for Family Medicine Residents”. This document explains the day to day activities, goals, objectives and responsibilities.
newborn record page 1 admission
Newborn Record(Page 1 - Admission)
  • Maternal History and Delivery Record
  • Infant record
  • Initial Exam
  • Assessment and Plan

**Medical students should NOT write in the red area. They may document in the green area as long as enough room is left for you to document a full note. **

newborn record page 2 discharge
Newborn Record (Page 2 - Discharge)
  • Discharge Exam
  • Information to be included in Discharge Summary
  • Hospital Course Summary

**Medical students should NOT write in the red area. They may document in the green area as long as enough room is left for you to document a full note. **

pertinent maternal history
Pertinent Maternal History
  • Everyone involved in the care of the infant should have knowledge of the relevant maternal history
    • Pre-partum
    • Antenatal
    • Perinatal
  • This information can routinely be found on the maternal fact sheet in newborn’s chart (yellow form) or in the mother’s chart.
maternal fact sheet
Maternal Fact Sheet
  • Maternal History
  • Infant Record
  • Delivery Record

**Although the maternal serologies are listed on this sheet we do NOT believe them. All serologies must be confirmed by lab report!**

maternal history
Maternal History
  • Family History
    • Inherited diseases (cystic fibrosis, sickle cell disease, metabolic disease, polycystic kidneys, hemophilia, and history of perinatal death)
  • Maternal History
    • Age, blood type, chronic diseases, diabetes, hypertension, renal disease, cardiac disease, bleeding disorders, infertility, recent infections/exposures, rubella status, GBS status, and STD’s
maternal history9
Maternal History
  • Sexually transmitted diseases (STD’s)
    • HIV
    • Syphilis (RPR or VDRL)
    • Hepatitis B (HepBsAg)
    • Gonorrhea (GC DNA)
    • Chlamydia (Cz DNA)
  • Group B Streptococcus “GBS”
    • (streptococcus agalactiae)
    • Rectal/vaginal swab results at 35-37 weeks gestation

**all maternal results must be verified/confirmed by visualizing a lab report**

Group B Strep

maternal history10
Maternal History
  • Previous pregnancies
    • Abortions, fetal demise, neonatal death, premature births, postdate births, malformations, respiratory distress syndrome, jaundice, apnea
  • Drug history
    • Medications, drugs of abuse, ETOH, tobacco usage during pregnancy
maternal history11
Maternal History
  • Current Pregnancy
    • Gestational age, results of fetal testing, pre-eclampsia, bleeding, trauma, infection, surgery, polyhydramnios, oligohydramnios, glucocorticoids, labor suppressants, antibiotics
  • Important factors during labor……
slide12
Onset of labor: spontaneous vs. induced

Rupture of membranes

Placental exam

Analgesia

Presentation

Labor and Delivery:

Important Factors

Anesthesia

Maternal fever

Fetal monitoring

Apgar scores

Resuscitation

Method of delivery

Duration of labor

medical student progress note
Medical Student Progress Note
  • Include brief maternal and child history relevant to pregnancy and birth
  • S: Include subjective components
  • O: Include objective components
    • Include growth parameters, vital signs (highlow), I/O’s Include COMPLETE exam
  • A: Includes overall assessment of infant
  • P: Include plan
    • Identify risk factors and/or concerns for sepsis, jaundice, feeding, murmurs, social, etc.
newborn examination
Newborn Examination
  • A child’s first exam should be one of the most thorough the child ever receives.
  • The newborn assessment is different from an adult exam!!!
    • If you start at the head and plan to go to toes, a quiet child may no longer be quiet!
  • Look, listen, feel
    • Listen to heart, lungs, and abdomen while the infant is quiet, then attempt to work “head to toe”.
    • May have to continuously adjust your exam and examine what becomes available
cardiopulmonary exam
Cardiopulmonary Exam
  • Look at the chest
    • Color, symmetry, work of breathing, and respiratory rate
    • Observe for retractions, nasal flaring, malformations, abnormal pulsations, and parasternal heave.
  • Heart examination
    • Rate, rhythm, murmurs, gallops, clicks, loudest on right side or left side, location and strength of PMI (point of maximal impulse)
      • PDA murmur sound link: http://www.merck.com/mrkshared/mmanual/audio/197au23.jsp
    • Check femoral pulses and compare with brachial pulses
  • Listen to the lungs
    • Bilateral breath sounds, crackles, wheezes, or rhonchi
abdominal exam
Abdominal Exam
  • Inspect first
  • Listen for bowel sounds
    • Present or absent
  • Feel the tummy!
    • Palpate for liver, spleen, kidneys, and presence of masses
genitourinary exam male
Genitourinary Exam: Male
  • Penis: Phimosis is normal!!!
    • Do not attempt to retract the foreskin over the glans
    • Look for epi- or hypospadias
  • Testes: Feel both testes, look for hydroceles, hernias, or other abnormalities
  • Ambiguous genitalia
  • Anus: Check for patency and placement
genitourinary abnormalities male
Genitourinary Abnormalities: Male

Normal neonatal phimosis

www.vghtpe.gov.tw

Hypospadias

www.meddean.luc.edu

genitourinary abnormalities male19
Genitourinary Abnormalities: Male

Left hydrocele

www1.medizin.uni-halle.de

Left inguinal hernia

www.pediatriconcall.com

genitourinary exam female
Genitourinary Exam: Female
  • Labia:
    • Large labia major is common due to maternal hormones
    • Examine for fusion and clitoral hypertrophy
  • Vagina:
    • Vaginal discharge is common; white & mucoid to pseudomenses
    • May have hymenal tags
  • Ambiguous genitalia
  • Anus: check for patency and placement
genitourinary abnormalities
Genitourinary Abnormalities

Imperforate anus

www.bms.brown.edu

Ambiguous genitalia

www.thefetus.net

genitourinary abnormalities22
Genitourinary Abnormalities

Hymenal Taghttp://newborns.stanford.edu/PhotoGallery/HymenalTag2.html

extremities
Extremities
  • Digits: number and abnormalities
    • Examples: polydactyly, syndactyly, clinodactyly, simian creases
  • Arms/Legs:
    • Examine range of motion, tone, asymmetry
  • Clavicles
    • Feel for fractures!!!
  • Hips:
    • Barlow and Ortaloni exam
    • Clicks are common and benign due to estrogenic effect
    • Clunks are indicative of hip dislocation/relocation and can represent developmental dysplasia of the hip
extremity abnormalities
Extremity Abnormalities

Single Palmar Crease

www.emedicine.com

Polydactyly

www.mrcophth.com

spine
Spine
  • Flip infant onto your forearm and look at entire spine
  • Feel the vertebral column for bony defects
  • Examine sacral area closely
    • Clefts, hairy tufts, change in pigmentation
  • Look for gross defects
    • Meningomyelocele, teratomas, sinus tracts
vertebral abnormalities
Vertebral Abnormalities

Sacral Sinus and Dimple

www.adhb.govt.nz

Hair tuft

www.fammed.washington.edu

slide28
Skin
  • Look at the skin during the entire exam
    • Jaundice
    • Mongolian spots (Important to document!!!)
    • Rashes

- HSV lesions - Milia

- Transient pustular melanosis - Cradle cap

- Neonatal Acne - Stork bites

- Erythema toxicum neonatorum

skin findings
Skin Findings

Mongolian Spot (Congenital dermal melanocytosis) www.koori-childrens-clinic.com dermis.multimedica.de

skin findings30
Skin Findings

Erythema toxicum neonatorum

www.dermis.net www.nursing.duq.edu

Transient pustular melanosis

www.ahsl.co.nz ethnomed.org

skin findings31
Skin Findings

Sebaceous Gland Hyperplasia

www.ahsl.co.nz

Neonatal Acne

www.derm101.com

skin findings32
Skin Findings

Cradle Cap (Seborrheic dermatitis)

en.wikipedia.org

Stork bite (Nevus simplex)

www.ritari.org

heent
HEENT
  • Head
    • Head circumference (average 34-35cm)
    • Look and feel scalp
      • Caput succedaneum, cephalohematoma, abrasions, sutures, fontanelles (anterior and posterior)
  • Ears
    • Formed, pits, tags, rotation, position, size
  • Nose
    • Nares patent bilaterally
head findings
Head Findings

Caput succedaneum

www.fammed.washington.edu

Cephalohematoma

www.emedicine.com

heent35
HEENT
  • Mouth
    • Check for clefts (lip and palate), arched palate, neonatal teeth, Epstein pearls
  • Eyes
    • Scleral hemorrhages, icterus, discharge, pupil size, extra-ocular movements, red reflex, clear cornea
  • Neck
    • Range of motion, goiter, cysts, clefts,
heent findings
HEENT Findings

Cleft lip and palate

www.thefetus.net

Absent red reflex

www.stjude.org

Epstein’s pearls

www.dentistry.bham.ac.uk

neurologic exam
Neurologic Exam
  • Look carefully and evaluate neurologic status during exam of other systems
    • Symmetry of motion, tone, bulk, response to stimulation, pitch of cry, repetitive motions, palsies
    • Primitive Reflexes: Moro, suck, rooting, palmar/plantar grasp, stepping
newborn reflexes
Newborn Reflexes

Palmar and plantar grasp

www.winfssi.com

Rooting reflex

www.winfssi.com

newborn reflexes39
Newborn Reflexes

Moro reflex

www.nlm.nih.gov

Stepping reflex

www.imi.org.uk

newborn exam pointers
Newborn Exam Pointers
  • Listen first, a crying baby doesn’t promote a good listening environment
  • Take your time, develop a system, and use it every single time
  • Look at every square inch of the baby!
  • Follow-up any abnormalities
  • Don’t forget gestational age assessment
so what s the big deal with gestational age
So what’s the big deal with gestational age?
  • Gestational age can predict problems, morbidity, mortality, and can help you keep alert for certain problems
    • Pre-term infants are at a higher risk for:
      • Respiratory distress syndrome
      • Necrotizing enterocolitis
      • Patent ductusarteriosis
      • Apnea
    • Post-term infants are at a higher risk for:
      • Asphyxia
      • Meconium aspiration
      • Trisomies and other syndromes
gestational age birth weights
Gestational Age & Birth Weights
  • Gestational Age:
    • Pre-term: < 37 weeks
    • Term: 37-41 6/7 weeks
    • Post-term: 42 or more weeks
  • Term Infant (weight classification)
    • LGA: >4000 g
    • AGA: 2500-3999 g
    • SGA: <2500 g
gestational age classification
Gestational Age Classification
  • Pre-term, term, and post term infants must all be plotted to determine if they are SGA, AGA, and LGA with regards to weight, length, and head circumference.

LGA

AGA

SGA

X

X

X

summary
Summary
  • Be thorough
  • Be complete
  • Find a system and use it each and every time!!!
  • The more infants you examine, the more comfortable you will become with normal variations.
references
References
  • Nelson’s Textbook of Pediatrics, 17th ed
  • Gomella’s Neonatology, 5th ed
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